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HomeMy WebLinkAbout1273A 1274A � f , _ . . � WOR R COMPENSATION DECLARATION - � �� ` � � � �. -� �� �I. ereby af' t t I have.a certi.ficate of consent to s f °� C� � i sure,or ti cateofN/o�kers'Compensptioninsurane, � ��., APP�L�CAT�141�����FOR BUILDIN�G PERNIIT - � � r a�cer � c ihereof(Sec.3800,Lab.C.) � � �-� � � � �� � � �` - �- ��� �` -- � � " �� r � COUNTY OP LOS ANG�I:ES BUILDING AND SAFETY Policy .` Company ... . . _ . _. .. .. � C i ie copy is hereby fumished. FOR APPLICANT TO FILL IN qooeEss �' � C r1if� d copy is filed with the tounty building insper BUILDING � �' - � � ��, ��� � -- ���- �- -��� � � � t n epariment. A�DRE55���".?'0 " Daie ��APPlicant . . . .. GTV -. . . ..�.� .ZIP. . . . LOCALITY .. . CERTIFICATE OF EXEMPTION FROM W02KERS' � � - � � - - —-�-�NO.�OF BL�GS. -- � NEAREST..� .- . . .. .. . . . . . - ��COMPENSATION INSURANCE � - SIZE OF LOT NOW Onl tOi CRO55 ST. . (This section need noo be completed if the permif is for one � -� '-" � - � � -- -- �-�� - ASSESSOR �� � � -laundred dollors($100)or less.) . TRACT BLOCK LOT NO. Mqp g'pK � ' .PAGE PARCEL � . _` . , TEL . . .., _ -MAP... _ -1 certify thaf in ihe performance of the - OWNER -�� � ''-�����- � " . Y work for which this �' N��t,+� NO. s permif is�issued,I shall not employ any person in any manner qDDRES �� -- �--7�� �, ��'�"c.:� -''- ' � CONDITIONS o so as to become iubject�o ihe Workeis'Compensation Ldws. � � . . - 9-ry�,r� � -� � . v ,—_ . CITV� IR '�-... _... ... .ZIP _�/C.-LC./.' . ... . . � Date� A'pplicani, ARCHITECr OR TEL. Q NOTICE TO APPLICANT: If, diter makin ihr5 Ceriifitafe of � �, DISTRICT GROUP TVPE FIRE P O SEDBY � �empfion, you 'should become subject fo ihe Workers' � � ENGINEER Y'Ytl � N0.7��r�'.� ��`��� CONST. ZO V ,ompensation provis�ons of ihe Labor�Code,you m�stforth- ADDRE55� ""/' . � � �i "/ . OW. v✓iih cornply.with�SUch�provisions or�fhis p¢rmii shal.l be" -��� - � �-- - �� �'- ' - -TEL � �-� -� STATISTICAL C SIFICAi�qN � A . CONDO deemed revoked. � - � �� CONTRACTOR No. /t � — LICENSED CON7RACTORS DEGLARATION . � �� � �� - � ���, �- CLA55 NO.��NftL UNITS�� I hereby affirm ihaf I am licensed under provisio�s of Chapter 9 ADDRESS NO. (mmmencing wifh Section 7000)of Divisioh 3 of ihe Business and . . . . _. ., , .�i�,.. SeweR nnt�P � Protessions Code,and my license is.in full force and�effect. � CITY CV+55 " BK �: - - � � �--�VALIDATION�- � � � SQ.fT. NO.OF NO�.Of CHECK . �, License Number � Lic Class SIZE S70RIE5� ��� FAMIUES ONE , � . . . . . .VAWATIpN . . . . . . . . � �� � � DfSCRIPTIONOFWORK �� � �-" � '-'� '� NE�''� � s ��,;.]) �y�„�� C,onfractor � � Date � ADD Q i t `�•t�1 . � � �I am exempt under Sec: r ' �� q�hR � , z�� �?3��i . B.&P.C.for ihis reason � - S - - �- � -��� � � REPAIR m.J�. . _. . .. .Dpte: USE Of . . . .. . . �i a a DEMOL - E%ISTING BLDG. ❑ I ��i t��� � �Signatur . . . . . �� APpLICANT.._ . ... . ` � TEL �1 y��p� - �3 . WNER-BUIL�ER D LARATION � PRINT 'vY�"1�`,� 4"�� NOT�1��"s Y~ .. DA E` .� . - ... • �4 � .3 , � x . . .. . .. ___. , . . . .._; I hereby affirm that I am ezempt f m the Confrador's License ,�,y �,i " � law for the followirig.ceaSon(Section 7031.5,Business and AooRE55 -7 �>..)�✓' � "" k;,7j� � •'�(.� " t �- " . ¢ , FINAL/'/}' , j 2 2 2—._.�', . � Professions Code):. . _ .. .. . _. veeservr.. _.. . --.� . . - . . . . . . BY ��J� . . . - �� C�.4 r�� � � I, as owner of}he proper}y, ar my employees with ADDRE55 wages as their sole compensatian,will do the work ond �� � � ��`� ���� -�' ,�_". . r�� - �m • • ° •7" fhe sfructure is not intended or offered for sale(Se<tion LOCALIN . � � 7044,Business and Professians'Code').' � -- MOVING "� �� -' - �- TEt. - � ' -�� � - � Q 9�f)�:Q(} � I,qs owner of the property,am exclusively contracfing CONTRACTOR NO. � - . , ,- with licensed tonimctors to consiruct the�project(Sec- � � ---- � �-- ��� � � �� - � � - � - -- � � � ° R Y-��',G t:���.�r� fion 7044,Business and Professions Code). ADDRE55 , � . REQUIREO. .TOTAL SETBACK ROM IS7.. I �L 2�'�_G � � -�CONSTRUCTION CEN�ING AGENCY "-� ' �� SET BACK � ��YARD-- HWY pROP.LINE WIDTH � � � 1 hareby affirm that ihere is a construclion lending agency for FRONT _ .. ' �� the performon<e of the work for which ihis-permit-is issued - P.t. - -� - ---� - � � (Sec.3097,Civ.C.). SIDE � � m .Lender's Name � . . P.L.. . .._._.. . . . . . . . o � - J .• LDMA Ref.ti �� , . � . . . . .. . .. P.C.Fee S �-( ' ' Perm i Fee� �.� . .. - . . - Lender's Address f'� �� � � � I certify that.I.have.read this applicaiion and state that the .... ,� Issuance�fee �LDMA P�C# �V ly � '� � - ¢ abo�e informafion rs correcl.I agree to mmply wrth all CouMy � � . 7 � g ordinances and Siate laws relating.fo building wnsfrucfion, j .� _ .,T m4fae�- x�� LDMP,Perm.-#���/ - - � � and hereby author ze represeniatives of this Coun�y to enter � upon .e above-me tioned property for inspection purposes. �� ��E,�`� o ��'($A.yl,� (�'�/��ti-/ SEE REVERSE FOR EXVLAN�p�p's,RY LANGUAGE��� ' ^ Signat�re of Ap 1 ant or A9ent ..Dare ... ._1_�J�G'..j�/ . .- � . OO� � T /V PLANS TO APPLICANT INSPECTOR'S NOTES . OWNER-BUILDER D�C�ARATION . I hereby�affirm that f a exempt�4rom the Comractor's ����� ' „��. '�+'-�_���,J��,,,`n A� ens�` tor��-}�`2 tollnwing reason. �(Sec�703i:5) TO., � R@�VfltBd .�. �' .. !u, �� �S� � /�'" �.� � �� . � . ' � Approved "� . . . � Business and Professions Code:Any tdty or county which No. Doie No. ����Dafe � �����������,� '—�.�"�� -reguires m pernsit to construct,alter,improve,demolrsh�, , s _ -orrepairanystrucLssre,prior�todtc.rssuance,.misnregwir'es ' - . . ' � � , � _ � �� tbe¢pplicaxt fnr such permit to.file a siqneX statement � ���- . � ����� ��� -� �� � ..dAat be.is licensed pursuand To:tbe pravisions,of tbe Cnn- � � � . � � � , � '- trrsctus's Lice+tse Law(Gfiapter 9/(com.mencing with.Sec- �" .. . .. . �� ".. tion 7000J of I}ivision 3 of the Rusiness and Profession.c . ' � � � �� � -- ;��. � Codef or a{ut fie es exempt tber�m axd tl e bosisfor,the . ._. _ _ . . . ...__.. . _ . . � � � ��- � � � alleged examption.Amy,x�iolntion j Section 7031.5 by . RequGed . .Date Reeeivad ..- . . . ... . � � .�. ��� .. . .. . -. . �� ¢ny app[icant for a permit subjects 11�e applic¢nt to a civi! Approvalt��� or Approved . �� ' � . pen¢ltp of not more-tban fave hundrerl�llurs�/$500J./r - . Yes No . ��}� .. . � � �� �� - � - �� - `- �� ❑ I,as owner of ihe property,'or my employees with Water Cerfificate - � � . - . . . . . � . . - . wages as iheir sole<ompensation,will do the work,and - �,. - � � � � fhe siructure isfiot intended or offered for sale(Sec.7044) Healih Department .���. -.. � . .- .- - � -- .... ��.. -'�. . Business and Professions Code:TFie Contracto{'s License � - . Law does noi pply to an oumer of property wbo builds , �. Fire DeparimeM . . - -� � ��-- �--- - -- � — or improves thereon,and who does such work bimself pr I � � � . . � � - �. tbraugh.his�owva.empinyees, prouided tbat sucb-im-, Grading- , � � . -� � � - �. provemenis.are xot intended.or ojfered f r.sdle.-.' . � - . bowever,tbe building or improve1nent is.aold-witbin m. Geolagicai. � .. . . . �� � ..-,.. .:. . • . ye¢r of mmf�[etion, tbe owner•builder.wilT bave-the � burden f prnving that be did not build or imprbve-fnr Pedesirian:Pratect on� .:��, � � � , tbeQurPose of saleJ.-- � - .� �. � � (FenceJ(Canopy) � � ��- - - - --- - - � n I,�as owner pf the praperfy,om exdusively contrao (� . .. ting wilh licensed contractors to construct ihe p.oject;(Sec. �t! Special Inspectlon� � �� � " � . 7044)8usiness o-nd Professeons Code: T5e Contractors (Canc.)(Masonry)(Welding) ' L cense Law does noi apply to an awner nf property wbo � � -�� ' �� � " "'' - budlds or improves thereon,nxd"u�ho cnneracts for stic5 Lot Drainage � � - projects w(tb a contracto�/lice-naed¢ursuant to tbe Q\, � .: � ' .. .... .. .. . . . . . . . . Crintructor's License Lawf.�.. . .,. � . _ . . . . � . . � . � C\ Parking ' -. , � � � . - . ` � �� � �� � ' ��'� � -� .. - �"-�L (omexemptunder5ec ,6.&P.C.fortFis LS . . ' . . . . . .. reason � � � . . . , ;.: ...;.'- ,.�' .. , . ' -..; . . .. . . . . .. . , � � , Dafe �Owner �.� - ...� � � ' � � `... � ; �:. ..... . .. � - - � . . . , . , � . � . . APProvals Date Inspecior's Signafure � � � � � . � .. '; ��. _,..,. . . -� . .�.� INSPECTOR'S NOTES . Location— � � . �. . . .. .. .. ... (Setback$Yords) ,. _ � - � ` � ... . . . . . . . . . Foundations � � . . . �. .. . ,. Slab ��'' . .... . _ . . . . .� . .. . , �� , . . , Frame . . .., .�..:: c . - .,:.. , ,,.: . .;., . . . . . . - . . . Energy Insulation . . . . .`..�. .� . . . . . ... .� . � . `/"�! �oih�o,Ywau- _ Interior . .. . ' - � � Lath—Exterior -_.�._ . - .,- . .. ,:.-_ . �_> :•..:: :� . ..__. .. .. _ .. . . _ . . .,. Ho�se Number � . .... - . ... . ._;. .- � �,� .. .. _ .. _. . . � .. Carre<t&Posted - � � ' � � Final— . . .. ... . .-. . .. . _ .. � . :... .. ... .,.. _'. _ . � .. . . . . Enfer on Fronf � � � �